2013-14 Annual Report

Transcription

Children’s Kidney Network for the
East Midlands, East of England and
South Yorkshire
Annual Report 2013-14
www.emeesykidney.nhs.uk
Children’s Kidney Network for the East
Midlands, East of England and South
Yorkshire
Annual Report 2013-14
Network base:
Nottingham Children’s Hospital
QMC Campus
Nottingham University Hospitals NHS Trust
Derby Road
Nottingham
NG7 2UH
Direct Line: 0115 970 9420
Renal nurse pager: 07659 598269
Fax: 0115 970 9419
www.emeesykidney.nhs.uk
EMEESY ANNUAL REPORT 2013-14
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CONTENTS
1.
Introduction ....................................................................................................................... 4
2.
Staffing ............................................................................................................................... 6
3.
Activity at Nottingham children’s hospital....................................................................... 10
4.
Chronic dialysis ................................................................................................................. 12
5.
Transplantation ................................................................................................................ 15
6.
Antenatal services ............................................................................................................ 18
7.
Urology ............................................................................................................................. 18
8.
Urology Nursing................................................................................................................ 19
9.
Pharmacy.......................................................................................................................... 23
10. Dietetics............................................................................................................................ 23
11. Social Work....................................................................................................................... 26
12. Play ................................................................................................................................... 28
13. Youth work ....................................................................................................................... 30
14. Psychology ........................................................................................................................ 32
15. Activity in local centres .................................................................................................... 33
16. Critical Care Support ........................................................................................................ 34
17. Network management ..................................................................................................... 37
18. Transition ......................................................................................................................... 39
19. Education and training ..................................................................................................... 39
20. Audit. ................................................................................................................................ 41
21. Patient experience and feedback ..................................................................................... 41
22. Research ........................................................................................................................... 43
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1.
INTRODUCTION
I am delighted to introduce the 2013-14 Annual Report for the EMEESY Children’s Kidney
Network. Strictly speaking, this is the first network annual report though it follows in the
mould of the Nottingham Children’s Hospital Kidney Unit annual report that has been
published each year. Over the last year and a half we have focussed on developing locallydelivered services in partnership with local teams so that we cut down on the number of
journeys to Nottingham our patients and their families have to make, a round-trip journey of
up to six hours for some families.
We have recognised that this can only be done if we develop the local shared-care clinics
into multi-professional clinics as happen in Nottingham. We have tried to develop contacts
with local nurses and dietitians and at the same time, nurses and dietitians from Nottingham
have been attending more shared-care clinics. If we want local nurses and dietitians to
support care for children with chronic kidney disease we need to provide a supportive
education structure and so we have developed a twice-yearly themed education day for
various health professionals building on the medical education days that were already in
place. With these changes in place and a network steering group meeting every 3-4 months
to oversee governance, the EMEESY Children’s Kidney Network was born.
For some time we have had the desire to overhaul the website that was originally developed
for Nottingham Children’s Renal Unit some years ago. We are delighted that the new
EMEESY website has been developed as a resource for families affected by childhood chronic
kidney disease and the professionals who support them. It has received positive feedback to
date but to be truly effective it needs to be used regularly and developed in line with
feedback. You can read more about all these network developments in chapters 15 and 17.
Other areas of development over the last year include the development of biofeedback for
children with dysfunctional voiding (chapter 8) and the development of home-delivered
intravenous eculizumab therapy for children with aHUS, a rare complex type of kidney
disease. Nottingham has been one of the first children’s renal and urology units to develop
both these treatments.
We have been pleased to see the success of our attempts to engage with social media: the
EMEESY Facebook page has active participation and the number of followers for the EMEESY
twitter account is growing. Facebook seems to be popular to publicise fundraising events
but we hope it will also provide the means for families to communicate and support one
another.
Now that we have a basic network infrastructure in place, we hope to be able to justify the
investment needed to co-ordinate all the clinic administration, the education events and the
website. We also hope to be able to develop robust means of measuring outcomes for the
network and recording patient/parent feedback. We have agreed that from this year
onwards, the network steering group, the Nottingham annual time-out day and the network
annual general meeting should be used to hold to account the workplan that is produced
from the annual report and progress with the workplan will be reported in each annual
report from here onwards.
PAGE 4
In line with corporate thinking, we have moved to an April-March from a calendar year
annual report. I hope you enjoy reading of the EMEESY activity over the last year and I
would be very pleased to receive any feedback.
Martin Christian
Lead Consultant for Paediatric Nephrology
Network Lead for EMEESY Children’s Kidney Network
martin.christian@nuh.nhs.uk
August 2014
Young people from the haemodialysis unit switching on the Nottingham Christmas lights in 2013
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2.
STAFFING
MEDICAL STAFF
CONSULTANT PAEDIATRIC NEPHROLOGISTS
Dr Jonathan Evans (Clinical Director for Family Health; 0.6 WTE clinical)
Dr Farida Hussain (on maternity leave until December 2014)
Dr Martin Christian (lead consultant and network lead)
Dr Meeta Mallik
Dr Andrew Lunn
Dr Corinne Langstaff (PT locum until October 2014)
Dr Sudarsana De (maternity locum until October 2014)
TRAINEES
National grid trainee: Dr Hitesh Prajapati (from August 2013)
Special interest in nephrology (SPIN) trainee: Dr David Broodbank (February to July 2013)
General paediatric trainee: Dr Asheeta Patel (August to October 2013)
Special interest in nephrology (SPIN) trainee: Dr Adamu Sambo (February to July 2014)
David Broodbank has recently been appointed to a consultant post at Pilgrim Hospital in
Boston where he will be the link renal paediatrician; Asheeta Patel has been accepted onto
the paediatric nephrology national grid to begin formal training in Birmingham in August.
There are two junior trainees attached to the ward at any one time for 4-6 months. A
number of recent junior trainees have expressed an interest in careers in nephrology.
CONSULTANT PAEDIATRIC UROLOGISTS
Mr Manoj Shenoy (service lead for paediatric surgery)
Mr Alun Williams (transplantation and paediatric urology)
Mrs Nia Fraser (maternity leave until June 2014)
Mr Bharat More (locum consultant until April 2014)
TRAINEES
National grid paediatric trainee: Mr Paul Jackson
Paediatric surgical senior trainee rotates every 6-12 months
Surgical SHO rotates every 3 months
TRANSPLANT SURGEONS
Mr Keith Rigg, Mr Alun Williams, Mr Shantanu Bhattacharjya, Mrs Amanda Knight
Richard Bowen leads the team of seven recipient co-ordinators. Anne Theakstone and Karen
Stopper are the live donor co-ordinators.
PAGE 6
SUPPORTING SERVICES
Radiology: Dr Nigel Broderick, Dr John Somers and Dr Kath Halliday
Pathology: Dr Tom McCulloch and Dr Zsolt Hodi
NURSING STAFF
RENAL TEAM
Senior Paediatric Nephrology Nurse and Network Lead Nurse: Shelley Jepson
Clinical Nurse Specialist (Dialysis): Roy Connell
Clinical Nurse Specialist (Transplant): Kim Helm
Renal Nurse Educator: Diane Blyton
Renal Critical Care Educator: Molly McLaughlin
Renal Nurses: Kate Baker (Transplant), Sharon Mould (Dialysis), Monique Burgin (Nephrotic)
HAEMODIALYSIS TEAM
Junior Charge Nurses: David Cooper and Ian Buchan
Haemodialysis Nurses: Nichola Hughes, Angela Thomson and Helen Gregory
UROLOGY TEAM
Clinical Nurse Specialist: Christine Rhodes
Urology Nurses: Gill Young, Emma Gamble (maternity leave) and Caroline Ward
WARD E17
Ward Manager: Michelle Kirkland
Junior Sisters: Debbie Hiley, Frankie Wells and Amandip Kaur
Large team of staff nurses, clinical support workers and domestic staff
DIETETICS
Pearl Pugh and Emma Kelly. During the last year, Pearl has taken a part-time secondment to
neonatology. Her nephrology hours have been backfilled by Ruth Prigg.
PSYCHOSOCIAL TEAM
SOCIAL WORK
Suzanne Batte and Heidi Steward. Heidi retired in January 2014. We hope to appoint a
replacement full-time social worker later in 2014.
These posts are currently part-funded by the BKPA.
PAGE 7
PSYCHOLOGIST
Dr Kathryn Bradley commenced work at the start of 2013 and provides 3 sessions of support
per week. She was on maternity leave from June 2013 to June 2014.
PLAY
Play specialist: Claire Hardy
Nursery nurse: Rachel Niemand (from October 2013, charitably-funded for 12 months)
YOUTH WORK
Renal youth development worker: Dorro Hackett. This post is funded by the BKPA for 3
years until November 2014. She is supported by Donna Hilton who manages youth and play
services for the children’s hospital and the Nottingham Children’s Hospital Youth Team and
volunteers. Matt Tomlin, Young Adult Worker for Nottingham and Derby provides support
for young people transitioning to local units.
ADMINISTRATIVE AND SECRETARIAL STAFF
Team leader and network administrator: Judith Hayes
Other secretaries: Sandie McLauchlan (urology) and Pauline Leivers (medical), Vicky Cancemi
(urology) and Pam Greenbank (support). They are supported by a team of filing clerks.
Ward receptionist: Lynn Brand (until February 2014); Diane Walker (from June 2014)
Haemodialysis administrative assistant: Kate Frost (until April 2014); Kelly Gillingham (from
July 2014)
PHARMACY
Paediatric renal pharmacist: Andrew Wignell, supported by Claire Fosbrook, Lorraine
MacDonald and See Mun Wong (home delivery services).
EDUCATION
Teachers: Gary Mace and Karine Williams
Teaching assistant: Hannah Barbary
MANAGEMENT
General Manager for Family Health: Julia Scrine (until June 2014)
Assistant General Manager (Paediatrics): Jenni Twinn (to March 2014); Vicky Holden (from
April 2014)
Clinical Lead for Children’s Services: Angela Horsley (until June 2014)
Matron: Sally Shearer (until 2013); Jamie Crew (from 2014)
We wish Julia Scrine a happy retirement and Sally Shearer and Angela Horsley success in
their new jobs as Senior Nurse for Paediatrics at Bart’s and Lead Children’s Nurse for NHS
England respectively.
PAGE 8
SUPPORT SERVICES
We acknowledge the help and support from various services essential to running a
paediatric renal unit including the support from the renal unit technical staff for the running
of the dialysis machines and support in supplies administration. We are also grateful for the
housekeeping and domestic support provided on ward E17.
Families whose children are admitted to ward E17 benefit from the accommodation support
team and have access to chaplaincy support from Rev Anne Ladd and a team of multi-faith
chaplains from the main hospital chaplaincy.
VOLUNTEERS
Finally we are grateful for the voluntary support received from Pat Sands, Pauline Woods
and Denise Hardy supporting clinic and ward day care. We are also grateful for the
charitably-funded support from the Giggle Doctors and Opus Music who visit the ward and
haemodialysis unit each week.
PAGE 9
3.
ACTIVITY AT NOTTINGHAM CHILDREN’S HOSPITAL
3A.
WARD ACTIVITY
During 2013-14, there were 705 admissions, daycases or ward attendances for nephrology
and 425 admissions, daycases or ward attendances for urology. Data in previous years has
counted admissions to ward E17 indiscriminately of whether they were under the
nephrourology team or one of the other paediatric teams. From next year, we hope to be
able to differentiate between admitted patients, patients seen for daycase procedures and
children attending the ward for clinical review.
3B.
RENAL BIOPSIES
A total of 78 biopsies were done during the year, 52 native and 26 transplant. Numbers of
biopsies have stay relatively steady in recent years with two busier years during 2010 and
2011 as shown in the figure.
3C.
ACUTE KIDNEY INJURY
Ten children were admitted to ward E17 with acute kidney injury. Seven of those children
had haemolytic uraemic syndrome related to E coli O157. The other children had AKI
secondary to urological or other causes and none of these three children required acute
dialysis.
Of those children with HUS, all but one required dialysis which was needed for an average of
15 days. Two children were treated with peritoneal dialysis alone, one child received
haemodialysis alone (due to severe colitis) and three children required a combination of
peritoneal and haemodialysis due to complications with peritoneal dialysis.
PAGE 10
3D.
OUT-PATIENT ACTIVITY
For nephrology clinics in Nottingham during 2013-14, there were 374 new patients seen and
3067 follow-up patients. Overall there is a slight increase in numbers over the last 6 years
but new patient numbers remain fairly constant.
The overall increase has occurred despite the large increase in numbers of patients seen in
local shared-care clinics, particularly with new clinics starting over the last 12 months which
has meant many patients being repatriated to follow-up at their local hospital shared-care
clinic.
Figure showing new and follow-up clinic numbers each year from 2008 onwards. From 2012 the data has been
captured from April to April but the graph represents a 12 month period each time.
2013-14
2012-13
2011
New
2010
Follow-up
2009
2008
0
1000
2000
3000
4000
PAGE 11
4.
CHRONIC DIALYSIS
Dialysis therapies are provided at Nottingham Children’s Hospital for
acute and chronic kidney failure. Peritoneal and haemodialysis are both
used for both types of kidney disease. In addition, the haemodialysis
unit staff provide apheresis therapies which are used to treat a variety of
renal and non-renal diseases. This section deals with dialysis used for
chronic diseases; information about dialysis used to treat acute kidney
injury may be found in section 3 (Activity at Nottingham Children’s
Hospital) and section 17 (Critical Care Support).
Roy Connell, Clinical Nurse Specialist for Paediatric Dialysis
HAEMODIALYSIS
CURRENT WORKFORCE:
The haemodialysis unit is staffed by 3.2 WTE dedicated registered nurses. This consists of
two band 6 nurses (1.6 WTE) and two band 5 nurses (1.6 WTE; 1.0 WTE currently on
maternity leave) and is managed by a Clinical Nurse Specialist.
Staffing requirements fluctuate between 4.0 and 7.0 WTE according to the number and
dependency of patients. The staffing gap is filled by regular input from all of the specialist
renal nurses.
ACTIVITY 2013-14
Fifteen patients received haemodialysis as a chronic treatment, compared to 22 in 2012/13,
18 in 2011 and 29 in 2010). There were 1447 patient sessions during the year, compared to
1771 in 2012/13, 1684 in 2011, 2352 in 2010 and 2164 in 2009. Overall this represents a
slight decrease in the haemodialysis numbers but workload has been challenging due to an
increase in younger and more highly dependent children receiving dialysis.
The age range of children receiving haemodialysis was between 1 and 19 years.
Four patients were aged less than 5 years compared to seven in 2012/13 with one requiring
dialysis 6 days per week.
Patient movement during the year has seen:
3 patients transfer to adult services
3 patients transplanted
1 patient converted to PD
WORK-PLAN FOR THE NEXT YEAR:
Integration of the renal computer to allow ‘real-time’ electronic recording of dialysis
sessions.
Implementation of a home-haemodialysis service.
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PERITONEAL DIALYSIS
CURRENT WORKFORCE:
The day-to-day management of the peritoneal dialysis programme is
undertaken by Sharon Mould (pictured), a band 6 renal nurse (1.0 WTE)
overseen by a Roy Connell, a clinical nurse specialist (1.0 WTE). Alongside the
PD programme, the CNS and renal nurse have a regular haemodialysis
commitment.
Roy Connell, the CNS is also responsible for:
Management of the haemodialysis programme.
Home therapies (including Albumin infusions)
Shared Eculizumab service.
Apheresis programme
Ambulatory blood pressure monitoring
ACTIVITY DURING 2013-14
Fifteen patients received peritoneal dialysis over the last year (109 patient months). This is a
similar workload to that seen in the previous two years (18 in 2012/13 and 19 in 2011) but
still significantly down on the numbers seen in recent years prior to this (31 in 2010, 28 in
2009, 27 in 2008).
Five families were trained to undertake peritoneal dialysis at home. These annual numbers
are variable: 12 families were trained in 2012/13, 2 in 2011, 17 in 2010 and 8 in 2009). The
number of families trained compared to the numbers remaining on or transferring off PD is
reflective of the ever-changing nature and needs of the PD population.
There were 6 episodes of peritonitis giving an incidence of 1 in 18 patient months (1:18 in
2012/13, 1:14 for 2011, 1:17 for 2010 and 1:16 for 2009). The unit’s 5-year peritonitis rate is
1 in 16 patient months which meets the recommended Renal Association standard of 1 in 14
patient months. Almost half (47%) of the PD patients were aged less than 5 years during
2013/14 and therefore fall in the higher risk category for infections.
Patient movement during 2013/14 has seen:
1 patient transfer to adult services
5 patients transplanted
1 patient converted to haemodialysis.
8 patients remained on the PD programme.
WORK-PLAN FOR THE NEXT YEAR
Audit and review the changes made to the peritonitis guidelines (implemented June
2014).
PAGE 13
Further development of the update programme for PD patients.
APHERESIS THERAPIES
Apheresis treatments which include plasmapheresis (or plasma exchange) and lipopheresis
are treatments which involve removal of a part of the plasma to treat a diverse range of
acute and chronic treatments. Treatments are mainly performed in the haemodialysis unit
in addition to the regular patient workload. Therapies are carried out by the staff in the unit
or the on-call nurse during out of hours periods.
CURRENT WORKFORCE
There is no dedicated apheresis nurse for the unit so it is important for all of the
haemodialysis staff and specialist nurses to maintain their skills in the therapies we offer.
The apheresis programme is managed by the Dialysis Clinical Nurse Specialist.
Overall, the overall number of patients (acute and chronic) requiring apheresis therapies was
eight (compared to 13 in 2012/13, 13 in 2011, and 7 in 2010). However the number of
delivered sessions has remained constant (200 sessions of acute and chronic apheresis
performed during 2013/14 compared to 195 in 2012/13 and 174 in 2011).
Three patients received double filtration plasmapheresis (DFPP) as a chronic treatment – a
total of 172 individual sessions.
Five patients were treated acutely using apheresis for a number of differing conditions.
Therapeutic plasma exchange (TPE) was used to treat 2 patients (8 sessions) and DFPP to
treat 3 (20 sessions).
Two chronic apheresis patients transferred to adult services during 2013/14. One of these
was a long term patient with familial hypercholesterolemia who had been treated weekly in
the unit for almost 9 years.
WORK-PLAN FOR THE NEXT YEAR
Assess the need for a dedicated apheresis nurse to oversee the service, ensure skills
are kept up-to-date and implement any changes or new technologies.
Audit the therapies performed and complete the DFPP study
PAGE 14
5.
TRANSPLANTATION
Nottingham Children’s Hospital is one of 10 paediatric transplant units in the
UK. Both living donor and deceased donor transplants are carried out. We
aim to transplant all children pre-emptively where possible.
Kim Helm, Clinical Nurse Specialist in Paediatric Transplantation
WORKFORCE
There is one (0.8 WTE) band 7 clinical nurse specialist, Kim Helm. She is supported by a renal
nurse, Kate Baker (0.8 WTE) whose time is divided between transplantation and chronic
kidney disease. All paediatric nephrologists look after children who have been transplanted.
The surgical transplant team comprises four consultants, all of whom carry transplants in
children. There is a living donor team at Nottingham City Hospital where parents who wish
to be considered living donation can be referred.
The unit performed 13 transplants. At the end of the year there were just 4 patients active
on the national list with a further three suspended. This is relatively small number active on
the list for Nottingham. Many other children are currently being worked up for
transplantation.
Source of donor
Living donor
3
Deceased donor
9
Altruistic donor
1
Previous treatment
Pre-emptive
4
Peritoneal dialysis
7
Haemodialysis
2
Transplant number
First transplant
10
Second transplant
2
Third transplant
1
Post-transplant, patients are nursed either on the ward, PICU (if <15 kg) or PHDU (if 15-20
kg). There were six children nursed on the ward, five on PICU and two on PHDU. There were
more children nursed in critical care areas than desired because of insufficient nursing on
the ward to provide the 1:1 nursing required for the first 48 hours as a minimum.
PAGE 15
A total of 101 transplant patients were being followed-up throughout the year. There was
patient movement due to transferring to adult services, changing centres or deteriorating
graft function requiring a return to dialysis. At the end of the year there were 90 patients
under active follow-up. Most patients are followed in Nottingham clinics. There are some
children who receive their follow-up in local shared-care clinics; most of these children
return to Nottingham for an annual appointment.
Patients transition to adult centres within EMEESY. This year, five have transitioned to
Nottingham, four to Sheffield and two to Derby. One patient has died and two patients
returned to dialysis, both to peritoneal dialysis.
Transplant nurses liaise with other professionals throughout the network. Communication has
improved since transplant nurses have begun to attend local shared-care clinics with the
consultant on a regular basis. Kim Helm attended 5 such clinics this year. This can be combined
with updates for the families which can be carried in the clinic, saving on several home visits.
Living donor transplant numbers in Nottingham are low compared to other paediatric transplant
centres in the UK. In order to ensure that this is not due to a failure to share information about
transplantation options at an early stage, a first transplant family information day took place in
September 2013. The families of all children with CKD stage 4 and 5 were invited. The formal
programme included talks from a paediatric nephrologist, a transplant co-ordinator, the
transplant clinical nurse specialist and a member of the living donor team. The morning finished
with a talk from a parent who was a living donor for his child several years ago. Several other
families who had been through transplantation were also invited to be “expert” families and
after the formal programme there was a lunch with time for invited families to talk with
professionals or “expert” parents. The day was well attended (around 15 families) and excellent
feedback was received. There is a plan to repeat the day in October this year.
Transition has been a major focus this year with improvements in the transition process with
various adult units and the start of regular, successful multi disciplinary meetings. With some
larger centres, transition clinics have been just that – an opportunity to meet the adult team
alongside the paediatric team without the imperative to transfer care at the same clinic. In
Nottingham, we try to ensure that young people have at least two visits to the transition clinic
before transferring. Kim Helm attended 6 transition clinics.
Dorro Hackett, the youth worker and Kim arranged a coffee drop-in in Leicester in place of
multiple home visits. This was also supported by the adult transplant nurse. Two young people
and one carer attended.
Home visits are an essential part of our standard of care. This year, these included 18 home
visits, 13 school visits and 11 Team Around the Child or multi professional meetings.
There are regular 3-monthly meetings with the whole transplant team, including the tissue
typists from Sheffield. All children on or working towards the transplant list or preparing for
living donor transplantation are discussed. This enables good communication about potential
problems. The paediatric team has felt that a 3-month interval is too long for these discussions
and an interim meeting has been established during this year.
PAGE 16
Nottingham has been the first UK centre to take part in the international multi-centre CRADLE
study, trialling an immunosuppressant drug called everolimus which has previously been used
safely in adult transplantation and in a small number of children. Two other UK centres have
since joined the study. Nottingham is one of the top recruiting sites for this study of all
countries participating.
TRAINING, RESEARCH AND TEACHING
Conferences/courses attended:
Transplantation Day, Freeman Hospital, Newcastle, October 2013 (KH)
ITNS Chapter Birmingham 12th November 2013 (KH)
Paediatric Nephrology Nurses conference March 2014 (both)
Course : Motivational Interviewing workshop, Nottingham February 2014 (KH)
Masters of Nursing degree modules (KB)
Research time for RaDaR rare renal disease registry (KB)
Teaching to new starters: transplant on PICU, November 2013 (KH)
WORKPLAN FOR THE NEXT YEAR
We hope to continue to promote live donor transplantation, giving families an opportunity to
consider their child’s future treatment at a much earlier stage in the patients’ journey than
before.
We also plan to continue promoting living donor paired/pooled exchange where appropriate
and also ABOi donation.
We plan to develop the concept of a transplant annual review to ensure that all patients and
their families have a once a year overview of their transplant function and overall health.
Two of Nottingham’s Transplant Games
team for 2013, showing their medals.
PAGE 17
6.
ANTENATAL SERVICES
Antenatal counselling for pregnant women carrying babies with significant renal
abnormalities is provided from Nottingham for patients from Nottinghamshire and
Lincolnshire. This service is delivered by three consultant paediatric nephrologists in
conjunction with the Fetomaternal Medicine Department. Arrangements for delivery and
post-natal care are made as appropriate.
There were 32 infants referred post-natally in Nottingham but there are no data on the
number of women counselled for 2013-14. Next year’s report will contain information on
numbers of women counselled and infants delivered in Nottingham due to significant renal
tract abnormalities.
7.
UROLOGY
Urology surgical in-patients are nursed on ward E17. Other children who undergo day-case
procedures are admitted through the Ambulatory Care Unit.
WORKFORCE
There are 3 consultant paediatric urologists: Mr Manoj Shenoy, Mr Alun Williams and Mrs
Nia Fraser. Mr Williams also undertakes transplantation work for adults and children; his oncall is covering the transplant rota. Mrs Fraser returned from maternity leave in June 2014.
During her leave, Mr Bharat More covered her clinical work during her leave.
There is one national grid paediatric urology trainee and one paediatric surgical registrarlevel trainee.
2013-14 ACTIVITY
Clinics took place in Nottingham Children’s Hospital at the QMC Campus. Numbers of
children seen in Nottingham paediatric urology clinics are shown in the figure above. There
has been a 16% increase overall in out-patient activity from the previous year.
PAGE 18
As well as general urology clinics, there are monthly neuropathic bladder clinics and a
regular clinic for children with disorders of sexual differentiation that is run jointly with
paediatric endocrinologists.
Mr Williams does regular young persons’ urology clinics at the City Hospital Campus. He also
does operating sessions and clinics at Derbyshire Children’s Hospital and Chesterfield Royal
Hospital. Mrs Fraser does clinics at Kings Mill Hospital and Lincoln County Hospital.
8.
UROLOGY NURSING
2013-14 was a year in which we made many changes that not only improve
the quality of care we give but also to advance it. In January 2013 we
became only the fourth hospital in the country to offer children with
dysfunctional bladders the possibility of pelvic floor bio-feedback
management/training.
Chris Rhodes, Clinical Nurse Specialist in Paediatric Urology
WORKFORCE
In June we were also granted an extra 14 hours of band 5 time from our ward team. This
enabled us to increase Caroline Ward’s hours up to 26 hours a week for Urology. The
difference this makes will be demonstrated in our overall productivity.
ACTIVITY 2013-14
Our nocturnal enuresis service led by Caroline Ward continues to flourish and produces
some excellent results as you will read, we were asked to take on the nursing care and
overall management of children undergoing MRI urography and this has continued in 2013.
The number of children currently requiring our service is:
215 Children with a neuropathic bladder
211 Children with daytime enuresis
116 Young adults in the Young Persons’ Clinic
CHILDREN’S OUTPATIENT DEPARTMENT
Total number of children seen in clinics by the urology nurses in 2013-14 was 408, a similar
figure to that of 2012-13. This figure does not include the nocturnal enuresis clinic.
We continue to provide care and assessment within the out patient setting. During 2012-13
we had seen an increasing number of referrals from community paediatricians for our nurse
led clinic, which at times were overwhelming in their number. A managerial joint decision
was made that all new referrals have to be seen by doctor before they are referred into our
service.
PAGE 19
This year we came to the reluctant decision that we could no longer support the NephroUrology Young Person’s clinic. Our decision was taken in light of the amount of referrals we
were receiving for bladder assessments. Unfortunately as yet there is no adult urology nurse
to whom to transfer the young person’s care. This continues to causes some difficulties with
families still contacting the paediatric service once in the adult care.
NOCTURNAL ENURESIS SERVICE
A structured approach to nocturnal enuresis is offered. Baseline information is obtained to
enable ascertaining the child’s/young person’s problems and from this enuresis alarms are
issued and/or medications commenced. Medication or treatment decisions are followed-up
by phone, in consultant-led clinics and in the twice-monthly, nurse-led nocturnal enuresis.
There are have been 53 patients under the nurse-led enuresis clinic in the last year. 36 of
these patients have been issued an alarm during this year. 44% of these are now dry having
used the alarm only and a further 19% are dry with alarm and medication in combination.
Of these children 14 (26%) have undergone bladder assessment to add their management
DAY CASE ASSESSMENTS
The total number of children requiring day case bladder assessment was 175 which is an
increase of 15%. There are a large amount of referrals for this non invasive investigation
through which quite detailed information can be obtained about how the child’s bladder
functions on a day-to-day basis.
URODYNAMICS
Last year 71 children underwent this investigation, an increase of 39% from the previous
year. The service is supported by one radiologist and more recently two urologists, one of
who is due to return from annual leave in June 2014.
Since 2011 Entonox has been used for urethral catheterisation in the x-ray department
which has reduced the number of children requiring supra-pubic catheters to 12 in the last 3
years from over 20 per year. In turn, this has made a significant saving in the number of
general anaesthetics required. More importantly positive feedback from our patients and
their families has demonstrated an improved impact on our quality of care. These findings
were presented at the 2013 ESPU congress with Christine Rhodes subsequently winning the
Best Nurse Presentation at the conference.
CLEAN INTERMITTENT CATHETERISATION
40 children/parents, were taught clean intermittent catheterisation, plus a further 48
children were brought into hospital for their supra pubic catheter changes. As a result of
improved network working through EMEESY, nurses in Peterborough are now happy to
change supra pubic catheters locally which has reduced the number of families travelling to
Nottingham.
PAGE 20
COMMUNITY
We have carried out 31 homes and school visits which is similar to last year. We continue to
follow the agreement set that only essential home/school visits should be carried out and
when possible we have asked parents/carers and schools to travel in to hospital to see us for
teaching, training and other advice.
The service made 1780 phone calls to parents, 291 phone calls to health-care workers and
143 phone calls to schools.
BIO FEEDBACK
In January 2013 we became only the fourth children’s hospital in the country to offer pelvic
floor rehabilitation through bio-feedback. Each child is offered a course of 6 consecutive
weeks’ therapy and each session lasts for approximately 1 hour. We commenced our service
by seeing three children a week but more recently it has been necessary to increase this to
six children a week due to the increase in demand.
The children who would benefit from this form of treatment are those with dysfunctional
voiding (DV) which is a lack of co-ordination of sphincter and pelvic floor relaxation to enable
the child to void to completion.
23 children have attended for bio-feedback and 130 sessions have been completed.
ACADEMIC ACTIVITY
Christine Rhodes remains the chairperson for the RCN Children’s Urology Continence
Community, and continues to work closely with the RCN. She was the secretary for the
European Society for Paediatric Nurses (ESPUN) until May 2013.
All urology nurses have attended courses and meetings regularly through the year. Christine
Rhodes and Gill Young have continued to teach on a wide variety of educational courses,
study days and conferences:
May 2013. Chris Rhodes chaired the conference on children’s continence run by Coloplast.
June 2013 Chris Rhodes chaired the British Association of Paediatric Urology Nurses meeting
( as president) in Sheffield.
November 2013 Chris Rhodes and Gill Young taught on the bladder and bowel course in
Nottingham.
March 2014. Chris Rhodes presented on The Wet Child at the EMEESY Spring
Nephrouroradiology Symposium in Nottingham
April 2014 European Society of Paediatric Urology conference, Genoa, Italy. Chris Rhodes
presented Entonox, a gasp of air.
PAGE 21
WORKPLAN FOR 2014-15
To continue to develop the urodynamics service with a full complement of medical staff
supporting the service
To continue to develop and evaluate the new biofeedback service
To publish the experience of using Entonox to support urethral catheterisation for
urodynamics.
PAGE 22
9.
PHARMACY
Pharmacy services are provided by Andrew Wignell, whose time is divided
between the children’s renal unit and PICU. He advises on prescribing for inpatients and out-patients. He also advises paediatric pharmacists throughout
EMEESY on prescribing specialist renal drugs and gives advice about prescribing
in renal impairment.
Children with renal transplants and children with chronic glomerular disease, like nephrotic
syndrome may receive medication delivered to their homes through Healthcare at Home.
Over the last year, there have been problems with this service through a distribution base
move and the collapse of a competitor service leading to a significantly greater workload.
This is a situation that we continue to monitor closely.
Four children have been commenced on eculizumab for atypical haemolytic uraemic
syndrome and the drug is continuing in three children. This is an extremely high-cost drug
and use of the drug for atypical HUS is currently being assessed by NICE. All three children
now receive the drug at home, delivered by a paediatric nurse through a long-term port
device. This is a service supported by BUPA Healthcare. Nottingham has been the first
paediatric renal unit to use this service.
10.
DIETETICS
Nutritional support for children with chronic kidney disease is a key aspect
to management to support health and growth.
Pearl Pugh and Emma Kelly, Specialist Paediatric Renal Dietitians
WORKFORCE
The dietetic service is staffed by 1.6 WTE, Pearl Pugh (0.6 WTE) and Emma Kelly (1.0 WTE).
Cover is provided for all in-patients and CKD clinics that take place on a Tuesday and
Thursday morning. Only urgent referrals were seen in the Wednesday nephrology clinics.
During periods of full staffing a dietitian attended an outreach clinic with the consultant in
Leicester this has been identified as a priority for input. Both dietitians are members of the
Paediatric Renal Special Interest Group (PRING). Pearl Pugh is a member of the EMEESY
network steering group.
PAGE 23
CONTACTS
2009
2010
2011
2012
2013-14*
Total patients
225
224
187
188
242
New patients
87
71
76
70
74
1732
1765
1540
1456
1745
7.7
7.9
8.24
7.74
7.2
Total dietetic activity
Mean contacts
* Change to April-April analysis
BREAKDOWN OF NUMBER OF PATIENT CONTACTS
In-patients
Out patients
Dialysis unit
Home/school visits
Telephone
Total
2009
2010
2011
2012
2013-14
764
366
768
376
628
488
1
423
1554
1
430
1575
0
424
1540
622
561
64
1
187
1435
690
656
107
0
292
1745
TYPES OF TREATMENT CONTACTS
Dietary assessment - computerised
35
Dietary assessment - other
13
Healthy eating advice
176
Simple/single dietary recommendation e.g. low Na/low fat
6
Complex/disease-specific dietary advice e.g. low K and PO4
877
Controlled nutrient/portion
3
Oral supplements
386
Nasogastric tube feeding
327
Gastrostomy tube feeding
479
Central parenteral nutrition
Peripheral parenteral nutrition
Energy dense diet
39
3
128
Weaning advice
34
Nutrient-enriched infant formula
95
Total
2601
PAGE 24
TRAINING, RESEARCH AND TEACHING
EMEESY network – developing dietetic links and providing training and education for
paediatric deititians in regional shared care renal clinics (PP/EK)
Growth and nutrition audit update. To review the audit standards taking into account
feedback from other renal units and UK/KDOQI guidelines (EK/PP Sept 2013)
CONFERENCE PRESENTATIONS/COURSES ATTENDED
Paediatric Renal Interest Group Meetings (EK)
First International Paediatric Renal Dietitians’ Conference (EK)
Teaching methods course at Sutton Bonnington Campus (PP/EK)
East Midlands Leadership Academy Operational Leadership Series: Presenting with
Excellence (PP)
International Congress on Renal Nutrition & Metabolism. Presentation: What I tell my
families about renal diets for children with CKD. (PP, May 2014)
TEACHING
EMEESY multi-professional education meetings (PP/EK Oct 2013 and March 2014)
Teaching session for nurses, registrars and junior doctors on E17: dietary management of
CKD and AKI (EK)
Organised dietetic student training programmes, work experience sessions and student
mentor (EK)
Paediatric Registrar Training Day, Leicester (PP Sept 2013)
PLANS/ TARGETS FOR 2 014-15







To complete annual dietetic assessments involving analysis of 3-day food diary on all
dialysis patients and complete annual dietary assessment report.
Continued involvement in teaching of new staff and educating existing members of staff
with regard to the renal diet.
Continue to develop and review dietetic resources.
Continue to work on a strategy to improve phosphate compliance in children and young
people.
To identify a student to undertake a detailed literature review to look at the use
phosphate in preservatives.
Investigate the feasibility of undertaking some micronutrient status analyses pre and
post haemodialysis.
Undertake a service evaluation of gastrostomy for nutritional support in chronic
dialysis.
PAGE 25
11.
SOCIAL WORK
Social work support to children with chronic kidney disease and their
families has been provided by Heidi Steward (full-time post) and Suzanne
Batte (part-time post). The posts are part-funded by the British Kidney
Patient Association (until 2014). Heidi retired in January 2014 after 13
years. This has been a significant event, as the social work provision in
the team has been very stable for a long period of time. The full-time
post is currently vacant but Suzanne Batte continues to work part-time.
Heidi will be missed greatly by her friends and colleagues in the team, as well as the
numerous children and families she has supported over many years.
Suzanne Batte, Specialist Paediatric Renal Social Worker
ROLE OF THE SPECIALIST PAEDIATRIC RENAL SOCIAL WORKER
Chronic kidney disease is a life-long condition which has complex psychosocial implications
for the child and other family members which requires long term support. Heidi and Suzanne
have continued to aim to provide a high standard of psychosocial care to children and their
families through traditional social casework and counselling skills. This service is provided on
the renal ward, outpatient clinic and dialysis unit. The support offered includes being
available during ward admissions to discuss emotional, practical and financial implications.
Home visits are also undertaken to follow up needs in the community.
Heidi and Suzanne have continued to visit families with specialist renal nurses at critical
times during the treatment process including emotional trauma at the time of diagnosis,
prior to transplant listing and at the commencement of dialysis. Particular practical issues
that families face include storage and space when starting peritoneal dialysis at home or
coping with long journeys and treatment three times a week for those on hospital
haemodialysis. Sometimes a parent will have been forced to give up work too and so they
will require help to look at their finances. The BKPA are a great source of support for lower
income families and Suzanne continues to submit regular applications.
The broad range of backgrounds of families require individual responses. Suzanne is skilled
at assessing the needs of children from a wide range of religious and cultural backgrounds.
She also works with parents who have learning difficulties and mental health issues. Social
workers work with children who have involvement from Social Care due to safeguarding
issues. The impact of a specialist paediatric renal social worker is to ensure that local
authority social workers, teachers and other professionals understand the impact of chronic
kidney disease on families where there may already be substantial concerns. Being an
advocate for families whilst monitoring concerns is a difficult task to balance but having
experienced paediatric renal social workers who understand the thresholds for considering
when children may be at risk of significant harm are an essential part of the team.
Advocacy work is an expectation of the renal social work role. Heidi and Suzanne have
continued to represent the needs of children and their families with other agencies including
housing departments, employers, the Benefits Agency, schools, nurseries and further
PAGE 26
education establishments. We have sometimes been required to attend appeals tribunals in
relation to Disability Living Allowance.
2013-14 ACTIVITY
Suzanne and Heidi made 45 home visits in the last year. They attended 20 Child in
Need/Child Protection conferences/Core Group meetings, 13 Team around the Child (TAC)
meetings and made 10 school visits.
Heidi and Suzanne receive regular supervision from an experienced social work team
manager. This ensures that they can obtain advice about on-going work with families and
discuss care plans. The supervision also focuses on training and developmental needs as this
is a requirement for registration to practice as a social worker.
Both social workers are members of the BASW Special Interest Group which promotes the
work of renal social workers nationally. This ensures that they keep informed about
developments that impact on their daily work as indeed the group is a great source of
information and advice. Heidi attended BASW meetings during the last year and Suzanne
attended the Paediatric Special Interest Group meeting.
Heidi presented a paper at the 2013 EWOPA conference in Rotterdam regarding the
Transition Workshop that the team organised the previous year.
CHALLENGES FOR THE Y EAR AHEAD
At the current time, the social work provision is much reduced. However, effective planning
and organisation has ensured that the service continues, with priority given to children
subject to child protection plans, those receiving dialysis and children awaiting
transplantation. Suzanne is currently based more in the hospital during this period so that
ward patients and clinic patients continue to receive support. Weekly attendance at the
chronic kidney disease out-patient clinics ensures that Suzanne can see families and be
available to offer advice and support. For families attending infrequently, this provides an
opportunity to assess how they are coping. She is also currently working with her colleagues
to organise a second Transition Day in June 2014
It is clear that a comprehensive psychosocial service requires two social workers to ensure
that families receive support throughout the whole treatment process. We hope to appoint
a replacement full-time social worker later in the year.
PAGE 27
12.
PLAY
CURRENT WORK FORCE:
In this last year we have been able to expand to one full time health
play specialist, Claire Hardy (left) and, from October 2013, one 0.63
WTE nursery nurse, Rachel Niemand (right). This helps manage the
increasing workload and allows Claire to spend more time in clinic,
working with children to prepare for future treatments.
This graph shows the episodes of patient contact from August to March.
The types of intervention are broken down in the table below:
PAGE 28
SIGNIFICANT ACHIEVEMENTS:
Appointment of nursery nurse.
Development of new transplant preparation booklets
New documentation
More general play and play sessions carried out on the ward and in haemo due to
nursery nurse appointment
Now covering renal clinics so meeting more patients prior to needing specialist
support
PUBLICATIONS AND PRESENTATIONS:
Oxford Handbook of Clinical Skills
Presentation at Nottingham Trent University on the role of health play specialists
Organisation with the team of Nottingham Play Conference October 2014 (Chaired
the event)
Presentation to Japanese play staff visiting NCH
PLAN FOR 2014-2015:
To increase PT Nursery nurse to FT if funding is secured
To structure the way we work to ensure that all areas are covered (haemo, ward,
clinic)
To continue to do carry out home and school visits
To link with other renal play specialists nationally, including visiting other areas to
see how services are run.
PAGE 29
13.
YOUTH WORK
There is currently one Renal Youth Development Worker, Dorro
Hackett, working full time with the Renal Team. This post is a three
year post funded by the British Kidney Patient Association (BKPA)
which is due to finish in November 2014. There are currently plans to
extend the post.
Overall, 73 different young people and their siblings from the renal unit accessed youth
services during the past year. This could mean advice and support from the youth workers;
using the Youth Room during hospital stays; attending the weekly hospital youth club;
activity and support programs for long-term patients; transition support; and/or becoming
involved in long-term projects such as the Youth Forum, day trips and residential holidays.
This number accounts for 13% of young people seen by the Youth Service as a whole and
does not include young people admitted to E17 without renal conditions. 42 different young
people were seen in a clinic setting; this accounts for 70% of young people seen in clinic by
the Youth Service as a whole.
There were 55 episodes of young people from the renal unit accessing a day trip (23
different young people). This had increased from 21 contacts with 10 young people in 2012.
Trips included Laser Quest, ten-pin bowling, Drayton Manor Park Theme Park, Legoland,
Swadincote Ski and Snow Board Centre and a theatre trip – James and the Giant Peach. Four
young people met the Lord Mayor of Nottingham at the switching-on of the festive lights in
December.
27 young people from the renal unit accessed 38 residential activities. This was up from 15
contacts with 12 young people in 2012. Residentials included 5 days at the outdoor
education centre Newgale in Wales, a 3-day Transition Residential at Center Parcs and a 3day dialysis holiday to Center Parcs.
45 different young people were seen on ward E17 and in the Haemodialysis Unit. 16
different young people accessed support and/information through phone, email and
Facebook contacts. This information was not previously recorded in this way and so this is
the first opportunity to see the impact of this sort of work.
The impact of youth work is difficult define through numbers and statistics. Benefits of
having a renal youth worker that cannot be easily measured include: increased peer support,
1-1 support for young people around bereavement, housing, sexual health, independent
living, transition, driving and careers; opportunities to try new things; access to training and
educational support; encouraging young people to join the Youth Forum to have their say in
hospital services; and generally time away from the medical environment. Creating
opportunities for young people to learn about themselves and others is a key aspect of
youth work (NYA 2014). Over the last year, we have witnessed young people being able to
push their comfort zones through various activities and workshops and developing stronger
bonds with their peers.
PAGE 30
INNOVATIONS
2013 saw the introduction of coffee drop-in sessions for transition in people’s local
community. Six young people and their parent/carers were able to access support and ask
questions about transition. Alongside this, there were 39 contacts at a young adult clinic in
2013/14 and 4 1-1 visits to an adult unit. In March, three young people were asked to talk at
a Transition conference. One of these young people was a renal patient and he was able to
share his experiences of transition.
The Nottingham Children’s Hospital Grand Round in September 2013 focussed on the Renal
Unit’s transition pathway and included contributions from Dorro and the medical staff.
WORKPLAN FOR THE YEAR
We need to secure on-going, long-term funding for youth work, developing an evidencebase for its effectiveness and sharing practice with other specialties within Nottingham
Children’s Hospital yet to take full advantage of the NUH Youth Service.
Waiting to climb at the Newgale Young People’s Residential, July 2013
PAGE 31
14. PSYCHOLOGY
There are 3 sessions per week of psychology time to support children and young people with
kidney disease at Nottingham Children’s Hospital. This falls well-short of the
recommendations in the BAPN Multi-Professional Working document of 2003 which would
recommend … WTE for a service covering a population of 6 million. The current post-holder,
Dr Kat Bradley, has been on maternity leave for most of 2014-15 without locum cover.
Some psychological support is provided by other members of the psychosocial team
including play specialists, youth worker and social workers. We also refer to the paediatric
liaison psychiatry service at Nottingham Children’s Hospital and have benefited significantly
from the input of Mr Paul Fletcher, Systemic Psychotherapist with some of our patients and
families.
Just prior to going on maternity leave, Kat led a review of the weekly psychosocial meeting
which has been revised as a result. It is now chaired by a member of the psychosocial team
rather than the consultant on-service Minutes are taken with an agreed plan. These
minutes and plans are made available to the team through the confidential intranet sharedarea. At the start of each meeting, the outstanding action points from the previous week
are reviewed.
RESEARCH ACTIVITY
Jen Heath who was an assistant psychologist with the unit recently has completed a project
as part of her doctoral thesis exploring further the question of why self-reported quality of
life appears to be as high or higher in children and young people with CKD compared to their
health peers. A presentation has been accepted for the 2014 EWOPA meeting in Porto and
Jen is currently writing up the research for publication.
The prospect of securing additional hours is unlikely in the current financial climate. In the
next year, we plan to continue to develop the training role of the psychologist and explore
how some aspects of psychological assessment and treatment can be delivered by other
members of the team.
PAGE 32
15. ACTIVITY IN LOCAL CENTRES
With the network development secondments, 2013-14 has seen considerable growth in
numbers of children seen in local shared-care clinics. We prefer to consider these clinics as
shared-care rather than outreach or peripheral clinics to support our philosophy of
delivering quality care as close to home as possible in partnership with local services.
During this second phase of network development, we have sought to make multiprofessional links with local services. Nurses and dietitians from Nottingham have attended
many local shared-care clinics.
Growth in overall shared-care clinic numbers since 2000 is shown in the above graph. Over
the last year, new clinics in Doncaster, Bassetlaw (Worksop), West Suffolk Hospital,
Grantham, Barnsley, Great Yarmouth and most recently Hinchingbrooke (Huntingdon) have
started up. The predicted numbers for 2014 based on data for half the calendar year are
almost 1200 patients, an increase of 30% from 2012 before the network development
project began.
In the next financial year, we plan to revise all service-level agreements along the model of
Nottingham Children’s Hospital being responsible for activity in all centres, reimbursing each
local centre for “hosting” the clinic. This allows all the activity to bundled as specialist
commissioning and should result in smoother finance flows in future. We hope it will
eventually result in an appropriate tariff for paediatric renal out-patient services to fund the
large multi-disciplinary team that is required.
PAGE 33
16.
CRITICAL CARE SUPPORT
CURRENT WORKFORCE
The Renal Critical Care Educator, Molly McLaughlin (0.8 WTE), provides
specialist nursing support and education for staff caring for children within
the regional PICUs covered by the EMEESY network. This includes
Nottingham, Sheffield and Leicester (Glenfield and Leicester Royal
Infirmary). Some support is also provided to Addenbrookes, but this is more
as an in reach rather than outreach service.
Renal critical care education focuses mainly around Continuous Renal Replacement
Therapies (CRRT). There are increasing numbers of children with acute kidney injury (AKI).
requiring CRRT within PICU’s, however the frequency and predictability of these treatments
remains very varied. This means competence and confidence of PICU staff in delivering such
specialised treatments can vary greatly. The renal critical care education support therefore
aims to increase exposure to such treatments and improve their knowledge and practical
skills through simulation, ad hoc bedside teaching, formal classroom teaching or study days
and supervised practice when a patient is undergoing treatment.
Seventeen patients received acute dialysis therapies within Nottingham Children’s Hospital
(8 had haemodialysis, 4 haemofiltration, 6 peritoneal dialysis, 2 plasma exchange and 3
double filtration plasmapheresis). These were either delivered on ward E17, PICU, PHDU or
NICU.
The figure shows the number of sessions delivered in comparison with previous years (as
haemofiltration is a continuous therapy 1 session is equal to 1 day of treatment).
No. of sessions
Acute RRT in NUH 2009-2013
90
80
70
60
50
40
30
20
10
0
Haemodialysis
Haemofiltration
Peritoneal Dialysis
Therapeutic Plasma
Exchange
Double Filtration
Plasmapheresis
Apr 2009- Apr 2010- Apr 2011- Apr 2012- Apr 2013Mar 2010 Mar 2011 Mar 2012 Mar 2013 Mar 2014
Haemofiltration sessions have reduced whilst delivered sessions of peritoneal dialysis have
increased over the last 2 years. In contrast, haemofiltration sessions have increased across
PAGE 34
the EMEESY network as can be seen from the figure below. In particular haemofiltration in
Leicester (solely at Glenfield Hospital) has increased markedly.
Acute RRT in Critical Care Areas across
NUH Haemofiltration
EMEESY Network
No. of patients
SCH Haemofiltration
35
30
25
20
15
10
5
0
UHL Haemofiltration (data
missing 2009 & 2011)
NUH Peritoneal Dialysis
UHL Peritoneal Dialysis
NUH TPE
2009
2010
2011
2012
Year
2013
UHL TPE (new treatment
2011)
NUH IHD
SIGNIFICANT ACHIEVEMENTS/INNOVATIONS
2013-14 has been a varied year across the network. Despite much work directed towards
setting up a new service for continuous veno-venous haemofiltration (CVVH) at Leicester
Royal Infirmary (LRI) PICU, the first patient was not treated until 2014. This has meant trying
to ensure the skills and knowledge of nursing is maintained has proved quite demanding.
The demand for Therapeutic Plasma Exchange (TPE) for sepsis at Glenfield Hospital PICU
continues to grow. Ensuring the core team of nurses were able to deliver this service at
Glenfield Hospital was necessary to optimise service delivery, meaning an expansion of the
initial team that had been set up in 2011. More work is planned for 2014 to consolidate the
initial study day staff attended.
January 2014 saw the start of a new follow up pathway for all children who have received
RRT for AKI within the regional PICU’s. Now all children who fall within the EMEESY
catchment area will be followed up for a minimum of 5 years following AKI within PICU.
More links with Addenbrookes Hospital were developed in 2013. The Renal Critical Care
support extended to NICU to support the delivery of peritoneal dialysis, a treatment usually
only delivered at NICU at NUH. Stronger links were also formed with PICU, with plans for
2014 to teach on their critical care course at Anglia Ruskin University and places on the
Regional CVVH Simulation Day extended to staff here.
Sheffield PICU had a quieter year than usual from a CRRT perspective, but on the whole
were a lot busier throughout the year. This meant maintaining skills, competence and
confidence was even more challenging, as support to enable staff to attend formal study
days was limited.
PAGE 35
PUBLICATIONS/INVITED LECTURES
August 2013 – Taught on AKI and RRT, on Paediatric Critical Care Module at Sheffield Hallam
University
September 2013 – Taught on AKI and RRT, on Paediatric Critical Care Module at De
Montford University
24th September 2013 – Presented on ‘Initiating TPE on PICU’ at CRRT in PICU Conference at
King’s College Hospital London
November 2013 - Taught on Managing fluids in infants and children, AKI and RRT, on
Paediatric Critical Care Module at University of Nottingham
Member of PICS Renal Sub Group
WORKPLAN FOR THE YEAR
LRI have just successfully treated their first patient on CVVH. This required a lot of renal
critical care support and has highlighted some areas for future development through further
education and training with plans to expand the initial team of nursing staff.
September 2014 – the first regional CVVH simulation study day in Nottingham.
Citrate anticoagulation will be explored further, with the possibility of developing
guidelines/protocols and rolling this out at Nottingham Children’s Hospital.
PAGE 36
17.
NETWORK MANAGEMENT
At the end of March 2013, we had completed a 5-month secondment project funded by a
resilience grant from East Midlands Strategic Health Authority. During that time we
demonstrated:
That there were areas for quality development and cost savings with new shared
care clinics
That families paid a high price for regular travel to Nottingham in terms of the
economic impact for them and the family disruption it caused
That it is possible to develop local nursing and dietetic contacts
The organisational achievements of the secondment included:
Organising a one-off multi-professional meeting
Securing verbal agreements to establish 5 new shared-care clinics
Establishing a network steering group, chaired by a specialist commissioner, to
oversee governance of the network
Setting up a Facebook site to be able to communicate with parents/patients
It was clear that more time was required to put into place many of the initial plans and we
were grateful that Nottingham University Hospital Trust agreed to continue funding the
secondments for a further 12 months through internal charitable funds.
In the last 12 months, we have built upon the achievements of the initial 5-month
secondment to:
Establish new shared-care clinics in six centres: Doncaster Royal Infirmary, Bassetlaw
Hospital, Barnsley District General Hospital, Grantham District Hospital, West Suffolk
Hospital (Bury St Edmonds) and James Paget University Hospital (Great Yarmouth).
Develop multi-professional links with shared-care clinics with a Nottingham
paediatric renal nurse accompanying the paediatric nephrologist for 2 clinics per
year and a Nottingham dietitian attending yearly. These clinics are used to support
local nurses/dietitians and encourage further links.
Organise two further multi-professional education days, establishing a pattern of
twice yearly events which are subsidised by pharmaceutical companies to provide
low-cost education, particularly for non-medical staff.
Launch a new website for the EMEESY children’s kidney network which is aimed at
staff, patients and parents to provide information on our services, guidelines for
treatment of common conditions, dietetic, pharmacy and other resources for local
professionals to download, and links to other sources of quality paediatric renal
information.
Engage with the national peer review department of NHS England to develop a peer
review for paediatric renal services, sharing the experience of developing networks.
Write an operational policy to describe the current services offered by the EMEESY
children’s kidney network, mapping this to the NHS England standard contract.
We recognise the need for a core central team to ensure that this network is sustainable.
We have estimated that it will comprise: a full-time network administrator, 1-2 half-day
sessions of lead consultant time, 2 days of central nurse time (including lead nurse time and
PAGE 37
additional time for nurses to attend shared-care clinics) and around ½ day of additional
dietetic time.
Over the next year, we aim to make robust business cases for long-term funding of this
central infrastructure. The other elements of the network work plan for the next year
include:
Rolling out service level agreements for all new shared-care clinics and developing
existing ones.
Continuing to develop the work of the network steering group, particularly its role in
governance of the network.
Securing a shared-care clinic for Hinchingbrooke Hospital, the only local paediatric
centre in the EMEESY region without one now.
Developing the role of local paediatricians within the new and existing shared-care
clinics, aiming to have a local paediatrician in attendance in each clinic.
Aiming to increase the numbers of local nurses and dietitians attending educational
events.
Documenting patient pathways and agreeing these with commissioners.
Working specifically with Sheffield and Leicester Children’s Hospitals to develop
paediatric nephrology services there.
In March, we learnt that NHS England support for new peer review projects had been
withdrawn. We hope that work will resume at some point in the near future with a
competitive application process for which paediatric nephrology has already made some
preparation.
Data from the network secondment project showing numbers of children seen in Nottingham with
a closer local hospital. We hope to use this as a crude metric towards continuing to work towards
as many children as possible being seen in their local centres.
PAGE 38
18.
TRANSITION
Transition services have become a priority area for NHS England following the publication of
the Quality Care Commission (CQC) report on transition services across the country. We
have long-understood the consequences of poor transitioning of young people to adult
services. We continue to champion transition with the appointment of a key worker for all
young people with CKD who are approaching transition, specific transition clinics in the
major centres and specific transition-focussed activities such as transition residentials or
transition workshops.
Transition clinics took place twice yearly for Nottingham, Sheffield and Leicester patients
with a multi-disciplinary team meeting prior to each clinic. For Sheffield and Leicester
patients, one of these clinics took place in Nottingham and one in the unit to which the
young people will transition.
19.
EDUCATION AND TRAINING
Nursing Renal Education is supported by a part-time Paediatric Renal Nurse
Educator, Diane Blyton, at 0.76 WTE, over three days per week.
On average one day (one third) per week is used to cover the haemodialysis
unit. When the acute dialysis workload increases, this often increases. This can
impact on available time to spend on educational activities.
EDUCATION DELIVERED
Two ward time out days were delivered in May-June 2013 with renal educational content.
This enabled all nursing staff to attend one day for team building and updates in practice and
EMEESY network.
All newly qualified nurses (9) commencing on E17 on their first rotation had a two-week
supernumerary orientation period. This included a dedicated education day. This was not
provided for every nurse rotating to the ward. These nurses will receive input on the Study
days discussed below. Additional support provided as identified to staff on E17.
Two members of staff were trained to do Peritoneal Dialysis (PD) and most of the senior E17
nursing staff received a PD and central venous line update in 2013-14.
Teaching was provided for new staff on a Paediatric Critical Care study day.
Four Central Venous Access study days were provided, as planned for nursing staff across
the Children’s Hospital. Two additional sessions were provided for Paediatric Critical Care
and the Children’s Assessment unit. Ongoing support of assessment of practice is also
provided.
PAGE 39
The Paediatric Renal Nursing Team and Haemodialysis Unit officially became a spoke
placement for nursing students. We received an excellent evaluation following this.
SIGNIFICANT ACHIEVEMENTS OF THE YEAR
The Proposed Paediatric Nephrology Distance learning module secured guaranteed funding
of 10 places per year for 3 years from the Health Education East Midlands commissioners
this year. This addresses a concern by the Education Provider involved, that there would not
be sufficient students to make the module viable.
PUBLICATIONS/CONFERENCES
Diane Blyton and Shelley Jepson Renal Care in Infancy, Childhood and Early Adulthood
Chapter 12 in Renal Nursing. Fourth Edition (2014) Thomas, N. (Editor). Wiley Blackwell,
Chichester.
The Paediatric Nephrology Nurses Annual Conference was hosted in Nottingham in March
2014. The nurse educator supported the development of the conference, assisted in the
organisation on the day and chaired and facilitated discussion sessions on the day of the
conference.
WORKPLAN 2014-15
Renal and Urology study days are planned for June 2014, to continue teaching away from
the ward.
The aim is to provide teaching for staff away from the ward environment on an annual basis.
These will be offered to other nurses within the Network if the programme is appropriate.
Complete work commenced on developing practice and education on ward E17 to enable
patients requiring dopamine post transplantation to be nursed on E17.
Final work to be completed on the Paediatric Nephrology Module, to enable launch this
academic year.
Develop e-learning options for on-going education of nurses within the renal service and
EMEESY Network, at times when face-to-face education is challenging.
Continue to provide updates and training for extended roles for staff on E17.
PAGE 40
20.
AUDIT.
Audit is embedded as part of the clinical governance structures within Nottingham. It is
being developed across our network as part of the evolving clinical governance of the
network.
National audit data is submitted to the UK Renal Registry on all patients requiring dialysis or
transplant. This has been reported and our results are comparable to other paediatric renal
units in the UK. The reports may be viewed on the UK Renal Registry’s website
(www.renalreg.com).
Our outcome data regarding transplantation are also reported nationally as part of the
NHSBT Kidney Advisory Group data. These data are presented in the form of one and fiveyear data on patient and graft survival. Although within the expected statistical variation our
five year graft survival data is below the national average and will be the subject of an
internal audit in 2014.
General audit of practice as part of the Nottingham Children’s Hospital audit work plan
including consent, medical records, infection control and prescribing are ongoing. These are
regularly reported at the Children’s Hospital audit and governance meetings.
Local audit is facilitated through regular audit and governance meetings. The focus of the
audits includes growth and nutrition, anaemia, peritonitis rates, CVL infection rates and
renal biopsy complications. Our aim this year is to develop an audit work plan.
21.
PATIENT EXPERIENCE AND FEEDBACK
The EMEESY philosophy is to involve patients, parents and carers in the
development, day-to-day delivery and evaluation of our service. A number
of formal and informal communication methods have been used to ensure
that patients and their families have access to information and
opportunities to contribute to service delivery.
Shelley Jepson, Senior Paediatric Renal Nurse and PPI Lead
COMMUNICATION
Patients and families have access to the renal pager for 24 hour advice from the nursing
staff. An average of 30 calls per week are managed. Patients are able to contact their
consultant via secretarial staff and an appointment for call back can be arranged.
Renal Patient View is available to enable patients to view their blood results online from any
computer. Many families currently use this facility.
The unit continues to link families of newly diagnosed patients with others to promote
information sharing and peer support.
PAGE 41
INFORMATION
The network website www.emeesykidney.nhs.uk was launched in March 2014. This was
funded by the Kinder Appeal and is designed to provide information to young people, carers
and parents as well as professional staff. Social networking has been successfully
implemented. The EMEESY Facebook page has over 100 followers. Parents and carers
regularly post news, comments and questions via this site. The network joined Twitter in
January 2014 and has 10 followers to date.
INFORMATION EVENTS
“Nephrotic Natter”: Information day for families with a child with nephrotic syndrome. 10
families attended.
Transplant information day: Event to raise awareness of issues around transplantation. 15
families attended.
PATIENT AND CARER INVOLVEMENT
Three parents have volunteered to join the EMEESY steering group as user representatives.
None were able to attend the January meeting however feedback via meeting minutes and
discussion was provided. A separate parent feedback meeting will be arranged after future
steering group events.
WORK PLAN
Quarterly review and update of EMEESY website
Bi-annual steering group feedback for parents
Information events for transplantation, nephrotic syndrome and transition
Involve patients and carers in development of new information resources
Support families to attend transplant games
PAGE 42
22.
RESEARCH
Research is considered a core part of the clinical care that is delivered in
Nottingham and across the Network. At Nottingham and within EMEESY we
have a good track record of involvement in multi-centre clinic research.
Dr Andy Lunn, Research Lead for Paediatric Nephrology at Nottingham
Children’s Hospital
WORKFORCE
Currently there is 1 WTE research nurse within the Clinical Research Network (CRN) who is
employed to facilitate the research work in Nottingham and a second nurse working 0.5 WTE
in research specifically within the department (appointed in January 2014). Other members
of the clinical team in Nottingham are also involved in research according to the
requirement of active studies at that time. There is 1 PA of consultant time, supported by
the CRN, which is divided between the 5 consultants. This includes one consultant, Dr Andy
Lunn, who is a member of the British Association for Paediatric Nephrology / CRN clinical
studies group.
RESEARCH ACTIVITY
The research activity is divided between commercial studies and non-commercial studies
supported by NIHR funding. All research is conducted ethically approved and performed
according to Good Clinical Practice standards and guidelines. Details of current studies and
numbers of recruited patients are shown in the tables below.
The intention of the British Association for Paediatric Nephrology / MCRN clinical studies
group, and shared by our network, is to work towards being able to offer every patient the
opportunity to be involved in research.
Paediatric nephrologists and the CRN team support multi-centre studies in other local
centres, such as the PREDNOS and PREDNOS 2 studies of nephrotic syndrome, where
patients need to be identified and recruited in general paediatric centres.
REGISTRY STUDIES
Study Name
Summary
Contact
aHUS Eculizumab
Regsitry
Registry based study of aHUS
NB –links with RaDaR aHUS registry
Jonathan Evans
Olivia Silkstone
RaDaR
Rare Renal Disease Registry
Martin Christian
Kate Baker
PAGE 43
COMMERCIAL STUDIES
Study Name
Summary
Recruitment
Contact
actual (target)
CRADLE
Unblinded RCT of Everolimus, low
dose tac and steroid withdrawl vs
standard pred, tac and MMF.
Consent at transplant, randomise at
4-6 weeks after transplant.
6 (5)
Martin Christian
Lindsay Crate
CONNECT
MCI-196-E14
Unblinded, randomised dosing,
safety and efficacy study of
Colestilan (phosphate binder) in
dialysis patients. Screening, washout
then 17 weeks of fixed dose
randomised to calcium carbonate
(control), low, medium or high dose
Colestilan.
0 (2)
Andy Lunn
Olivia Silkstone
CONNECT
Variable Colestilan dose extension of
above study.
0 (2)
Andy Lunn
Olivia Silkstone
2 (1)
Study complete
Jonathan Evans
Olivia Silkstone
MCI-196-E15
aHUS Eculizumab Open label trial of eculizumab in
aHUS
NON-COMMERCIAL STUDIES
Study Name
Summary
Recruitment
Contact
(target)
Genetic basis of renal
tract abnormalities
Genetic study – one blood test, clinical
proforma recording medical history and data
collection sheet.
Study also recruiting parents of affected
children.
20 (20)
Andy Lunn
Olivia Silkstone
PREDNOS
Blinded placebo controlled RCT of short versus
long course of steroids for initial treatment of
nephrotic syndrome.
8 (6)
Andy Lunn
Anna Frost
PREDNOS 2
Blinded placebo controlled RCT of 6 days of
2
15mg/m prednisolone at time of URTI to
prevent nephrotic relapses.
5 (6)
Martin Christian
Olivia Silkstone
HOTKID
An unblinded randomised trial of standard (50th
th
75 centile) vs aggressive (<40 centile) control
of blood pressure in patients with CKD.
6 (5)
Andy Lunn
Olivia Silkstone
RaDaR – SRNS
Genetic and steroid response study in patients
with steroid resistant nephrotic syndrome.
Requires one blood test.
Genetic and immune system testing in patients
with MPGN.
Requires one blood test every 6 – 12 months.
RaDaR - MPGN
Martin Christian
Kate Baker
Martin Christian
Kate Baker
PAGE 44

2013-14 Annual Report

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